So, the pt was a elderly female in her 70s with a PMHX significant for HTN and Hyperlipidemia. She presented to the ER with a chief complaint of sudden onset chest pain radiating to her back x4h. She described her pain as “sharp”. She was extremely hypertensive, around the ballpark of 220/110. She denied a Hx of a previous MI, CAD, or CVA, as well as no previous history of an abnormal stress test, with one being performed within the last year and normal. She had a family history of CAD with family members having CAD/MIs in their early 50s. She denied smoking or drinking and lived with her family at home.
Her exam was mostly normal except for the mild to moderate distress she was in secondary to pain and discomfort. There were no palpable masses in her abdomen and she had no abdominal tenderness. Heart sounds normal without any murmurs, rubs, or gallops. Lungs were clear in all fields. She had no previous history of an Aneurysm. Differentials were: ACS, Hypetensive urgency, PNA, PTX.
Lab results came back grossly normal. CBC was clear with no elevation of white blood cells or decrease in her H&H. CMP showed no electrolyte abnormalities. Her cardiac enzymes were normal with no increase in troponin. EKG showed normal sinus rhythm with a First degree AV block, which was found to be old by examining a previous EKG.
Her radiology studies are when things go abnormal.
CXR is similar to this:
(DISCLAIMER: I am not providing an interpretation of the radiology studies. I’m giving both my opinion and the interpretations by a radiologist. Also: These are not the actual images of the patient. these are similar images found on the internet. )
Alright, so. This might not be the best chest x-ray but it was the most similar I could find. The mediastinum is widened and the apical cap is not well defined. The heart is enlarged as well. Due to the clinical correlation of acute chest pain radiating to the back and the chest xray findings, a CT angiogram of the chest and abdomen was ordered.
These are similar images:
Okay so this is the CTA of the chest. The abnormality here is the abnormal widening of the descending aorta (which is the vessel you see just adjacent to the spine). It’s widened to about 3.5 cm x 2.5 cm, suggestive of a thoracic aneurysm. While it is aneurysmal, this part of the aorta is not rupturing.
Here is the CT with contrast of the abdomen (This CT image is without contract but it still gets the point across)
This is where things get dicey. What you see just anterior to the spine is the abdominal descending aorta, which is widened. You can see some stranding around the aorta and an abnormal fluid present which is suggestive of a rupturing AAA.
An Abdominal Aortic Aneurysm is a ballooning/dilation of the abdominal aorta. In this case it was rupturing, which has a very high mortality rate of 60-90%. It usually presents in men between the age of 65-75 who are smokers or who have a family history of AAAs.
Cardiovascular surgery was consulted and the patient was started on a Cardipine drip to control her hypertension and she was taken to surgery within 25 minutes, where the AAA was repaired.
Overall a very interesting case!